Update on Maternal and Neonatal

Tetanus Elimination Programme

Strategic Advisory Group of Experts on Immunization

(SAGE) Meeting

Geneva, 19 October 2016

Azhar A Raza, UNICEF HQ

1

Presentation outline

Definition & Strategies to attain MNT elimination

Achievements and successes

Lessons learnt and success factors

Country Experience

Current targets and needs!

Status of remaining 18 countries

Critical challenges

Innovative approaches

2

MNT Elimination

Defined as:

Less than one Neonatal Tetanus (NT) case per 1000 live

births in a year in every district of a country.

If NT is eliminated,

maternal tetanus (MT) is also considered eliminated.

3

Strategies to attain MNTE

Immunization with TTCV

o Pregnant women during routine immunization

o All women of reproductive age (WRA) in high

risk districts through SIAs

Clean delivery & cord care practices

o Clean hands, birthing surface & cutting tools

o Clean cord care

NT surveillance

o As part of Integrated Disease Surveillance &

Response (IDSR)

4

More than 75% reduction in NT mortality

since 2000

5

20

0,0

00

18

0,0

00

12

8,0

00

[VA

LUE]

58

,00

0

49

,00

0

62 62

61

63

61

59 65

70 74

70

68

71 75 66

66

69

0

10

20

30

40

50

60

70

80

90

100

-

50,000

100,000

150,000

200,000

250,000

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015

Reported TT2+ coverage & estimated NT deaths 2000-2015

Neonatal Tetanus Deaths TT2+ (%)

TT 2+ C

ove

rage (p

erce

ntage

) Es

tim

ate

d n

um

be

r o

f N

T D

eat

hs

Source: WHO vaccine-preventable disease monitoring system, 2016 global summary

More than 150 million WRA received > 2 doses

of TTCV

6

8 14 23

39 45 57 62 69 76

100 112 116 119 123

134 144 148

151

1 3

5

9 11

15 17

19 21

27

30 33 34

37

39

43 44 41

-

50

100

150

200

250

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Wo

me

n o

f R

ep

rod

uc

tive

Ag

e (

WR

A)

(Mil

lio

ns

)

WRA Protected by SIAs WRA targeted but not protected with SIAs

Source: WHO database as of September 2016

Gradual increase in women delivering with assistance of Skilled Birth Attendants

7

94

66

83

69

29 36 36

56

98 93 94

80

49 49 54

75

-

20

40

60

80

100

CEE/CIS EAPR LACR MENA South Asia ESAR WCAR World

Skilled Birth Attendants Trends by region 2000-2015 (%)

2000 2015

Inequities among regions

Source; SOWC 2016

CEE/CIS - Central and Eastern Europe and the Commonwealth of Independent States EAPR - East Asia and the Pacific

LACR - Latin America and Caribbean MENA - Middle East and North Africa

South Asia ESAR - Eastern and Southern Africa WCAR - West and Central Africa

Low ANC4 Coverage and High ANC1-4 dropout

in South Asian and African Region

8

96 95 96

85

69

80 76

85 85 82 87

63

42 45 52

58

-

20

40

60

80

100

CEE/CIS EAPR LACR MENA South Asia ESAR WCAR World

ANC1-ANC4 coverage by region 2015 (%)

ANC1 ANC4

Source; SOWC 2016

CEE/CIS - Central and Eastern Europe and the Commonwealth of Independent States EAPR - East Asia and the Pacific

LACR - Latin America and Caribbean MENA - Middle East and North Africa

South Asia ESAR - Eastern and Southern Africa WCAR - West and Central Africa

41 Countries eliminated MNT between 2000 & Sept 2016 *(Plus Ethiopia except Somali region, and 16 out of 17 regions in Philippines)

Source: WHO/UNICEF Database

Date of slide : 08June 2016

Map production: Immunization Vaccines and

Biologicals, (IVB), World Health Organization

The boundaries and names shown and the designations used on this map do not imply the

expression of any opinion whatsoever on the part of the World Health Organization

concerning the legal status of any country, territory, city or area or of its authorities, or

concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent

approximate border lines for which there may not yet be full agreement.

WHO 2016. All rights reserved

not eliminated

eliminated before 2000

eliminated from 2000- Sept 2016

not applicable

countries yet to eliminate MNT18

1999

2016

6 countries achieved MNT elimination

without any TT SIA !

9

MNT Risk in most of the remaining countries

is narrowed down to few districts (High Risk)

high risk

no risk

medium risk

MNT eliminated

District level elimination status of MNT in the remaining 18 priority countries

Source: WHO/UNICEF Database

Date of slide : 08June 2016

Map production: Immunization Vaccines and

Biologicals, (IVB), World Health Organization

The boundaries and names shown and the designations used on this map do not imply the

expression of any opinion whatsoever on the part of the World Health Organization

concerning the legal status of any country, territory, city or area or of its authorities, or

concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent

approximate border lines for which there may not yet be full agreement.

WHO 2016. All rights reserved

10

Other achievements

• TT Uniject – discussions with manufacturers and donors in

progress 50 million devices needed over 4 years for 18 million WRA

Obtainable!

• Guidelines on sustaining MNTE being finalized in the light of

inputs from SAGE WG members with key focus on: Sustaining high TT2+/PAB coverage

Integration with ANC platform

Opportunities for delivering booster doses of TTCV

Strengthening NT Surveillance

11

Lessons learnt; the success factors

National commitment, ownership and engagement

Timely availability of resources proved critical

Good planning and detailed micro-planning for SIAs ensured quality

implementation

Early and active community engagement in all elimination activities,

but especially TTCV SIA – necessary to avoid rumours

Strong monitoring & supervision of implementation

Strength of the health system for integrated delivery of ANC & EPI

services.

12

Country Experience

Papua New Guinea Risk status of provinces & districts assessed

Prioritization made on areas of focus

Haiti Risk status of departments & communes assessed – all found to be at

low risk

Validation survey initiated – suspended due to Hurricane Matthew

DRC Only 11 out of 517 health zones at high risk

Field assessment for surveillance & TT coverage planned

Monthly review of progress by ICC

South Sudan All planned activities completed (2012-16)

Last round in remaining 3 states – end of 2016

13

Country Experience (2)

China, Eritrea, Namibia, Rwanda, South Africa, Zimbabwe Achieved MNTE without any SIAs

India Validated in 2015

More than 90% reduction in NT case load (~200,000 in 1980 to 11,600

in 2013 – CHERG)

Major investments on safe delivery – financial incentives for institutional

delivery; communication and community mobilizations (ASHAs)

Indonesia Validated in 2016

Key focus on school based tetanus immunization

Regular TTCV boosters – 18m, 1st grade, 2nd grade and 3rd / 5th grade

Nationwide school vaccination campaign - every November

14

Current targets and needs!

18 countries yet to eliminate MNT, 2/3rd of them in Africa

Vaccinate ~70 million WRA with 3 doses of TTCV

Need innovative approaches for ~18 million (27%) of these WRA

that are repeatedly unreached with conventional service delivery

Need US$ 148 million to accomplish the task - including US$ 50

million for TT Uniject

15

Current Status of remaining 18 countries

Conducting last phase of activities & likely to be validated in 2016

(2 countries) - Ethiopia, Haiti(?)

Completing planned activities by end of 2016 for validation in

2017 (7 countries)

o Angola, Chad, DRC, Guinea, Kenya, Philippines, South Sudan

Completing planned activities by end of 2017 for validation in

2018 (3 countries) - PNG, Somalia, Sudan

Mix of low commitment & insecurity requiring advocacy and

appropriate technology for validation by end 2020 (6 countries)

o Afghanistan, CAR, Mali, Nigeria, Pakistan, Yemen

16

Critical challenges

Gap of 98 million US$ to support TT SIAs in high risk areas –

the areas unreached by current health services

Additional 50 million US$ for TT Uniject required to protect 18

million WRA in the hardest to reach areas in 9 countries

(geographical, security & HR constraints)

Ineffective integration of RMNCH and EPI platforms to optimize

maternal immunization

Ineffective communication to prevent and respond to TT vaccine

controversy - for instance Kenya 2014

17

Critical challenges (2)

Insecurity - war and armed conflict – (AFG, CAR, MAL, NIE, PAK, SOM, SUD, SSU, YEM)

Competing activities with limited capacity at national

and subnational levels

Voluntary medical male circumcision for HIV

prevention has exposed tetanus immunity gap in males

18

Innovations to reach ~40% of target WRA in 9/18

countries that are persistently inaccessible

19

1,921,066

-

1,852,455

15,969,450

20,113,077

324,670

3,176,539

1,677,350

3,094,937

29,917,234

1,036,210

987,104

1,234,970

4,530,550

5,290,764

1,231,692

903,490

934,239

2,063,292

18,212,310

0% 20% 40% 60% 80% 100%

Afghanistan (35%)

Central African Republic (100%)

Chad** (40%)

Nigeria (22%)

Pakistan (21%)

Somalia (80%)

Sudan (22%)

Sudan South** (40%)

Yemen (40%)

TOTAL

Accessible target Estimated inaccessible target

TT

Uniject

$3,110,391 $2,962,990

$1,235,670

$13,599,351

$15,881,284

$3,697,170 $2,712,007

$934,768

$6,193,382

$-

$2,000,000

$4,000,000

$6,000,000

$8,000,000

$10,000,000

$12,000,000

$14,000,000

$16,000,000

Afghanistan(35%)

CentralAfrican

Republic(100%)

Chad** (40%) Nigeria (22%) Pakistan(21%)

Somalia(80%)

Sudan (22%) SudanSouth** (40%)

Yemen (40%)

Financial needs to deliver TT Uniject US$

Additional cost of devices

Innovation (TT Uniject) - additional US$ 50 million

needed to reach 18 million WRA

20

Thank you

21

Source: WHO/UNICEF MNTE Database, as at 03 October 2016 For 2016, data is provisional. Date of slide 3 October 2016

Trend in women of reproductive age targeted with TT SIAs

Kiwanis joined P&G + doubling of amount

$62 mil GAVI IFFIm

$26 mil BMGF

8.7 7.4

11.5

20.0

8.3

16.4

6.6

9.0 8.7

30.3

15.6

7.1

4.0

5.9

12.9

14.6

4.9 3.4

0

5

10

15

20

25

30

35

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Wo

me

n o

f re

pro

du

ctiv

e ag

e (W

RA

) (M

illio

ns)

22

More than 90% reduction in NT mortality since 1990

23

1,270,000

787,000

580,000 490,000

248,000 200,000

180,000 128,000 59,000

58,000 49,000 9

16 15 19

21 22 26

29

37

41

55 57 56 55

59 57 58 57

62 59

62 62 61 63

61 59

65

70 74

70 68

71 75

66 66

0

10

20

30

40

50

60

70

80

90

100

-

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

Reported TT2+ coverage & Estimated NT Deaths 1980-2015

Est NT Deaths TT2+ (%)WHO-UNICEF Database

TT

2+

Co

ve

rag

e (p

erc

en

tage)

Nu

mb

er

NT

Dea

ths

NT

Eli

min

ati

on

MN

TE

MNTE Validation Surveys – progress & possible timeline

24

Colour of cells indicate the country situation as at 8 June 2016

Validated

Not validated yet/Tentative validation timeline

A ng o la

36* 30 25 C ha d

40 Ug a nda Burkina Fas o Co te dÍvo ire Ethio pia C o ng o D R

Indo nes ia (part) Indo nes ia (part) G. Bis s au Iraq 24 21 Ha it i Guine a N ig e ria

50 48 Co ngo Mo zambique Ethio pia (part) Timo r Les te India (part) India (part) Cambo diaP a kis ta n

(pa rt)Ke nya P N G M a li ® C A R

55# 54 Nepal Egypt 47 Turkey Indo nes ia (part) Ghana Ta nza nia Gabo n India (part) India Eq Guinea M a li ® (pa rt)N ig e ria

(pa rt)

N ig e ria

(pa rt)P a kis ta n

57 56 M a la wi Eritrea 53 To go 50 Za m bia Banglades h B urundi Myammar Liberia Camero o n Lao s P DR Madagas car ® Mauritania Indo nes ia P hilippine sP a kis ta n

(pa rt)

P a kis ta n

(pa rt)Ye m e n

Zimbabwe Namibia So uth Africa India (part) Rwanda Vie tnam India (part) India (part) India (part) Co mo ro s Benin Senegal China Sierra Leo ne ® India (part) P hilippines (part) Niger S o uth S uda n S o m a lia S uda n A fg ha nis ta n

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

# - with the independence of T imor Leste the number of countries increased by one

* - with the independence of South Sudan the number of countries increased by one

2016-17 list is tentative and actual implementation will depend on the outcome of indepths data review

Not validated yet/Confirmed validation timeline

43 .